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Abstract

Background: Goals are a fundamental component of health care and promote person centred practice by encouraging collaborative discussions and shared decision making between patient and health care practitioner. Transition Care Program (TCP) is a federally funded, goal-orientated, therapy-focused program that provides additional time after an acute health event for older adults to improve functional ability and decide on final discharge destination. This research investigated the client and staff experiences of goals in TCP.

Research Question: ‘“What are the lived experiences of older adults and staff in goal setting and pursuit at TCP?”

Methods: Perceptions and experiences of goal setting and pursuit in TCP were explored by interviews with clients and focus groups with staff. An interview schedule for clients was utilized at admission, discharge and three months after discharge. The same schedule was used in the focus groups with staff. All discussions were transcribed verbatim. Concepts were discussed between the three researchers and related back to the research question for relevance and true depiction of the phenomenon being studied.

Results: Clients’ goals were to go home and return to normal; goals that staff found too broad for the purpose of the program. Going to residential care instead of home was distressing for clients and establishing a ‘new normal’ required time and support. Clients were hampered by mental and physical fatigue, which affected them throughout their journey with TCP. Support bolstered mood and ability, although it changed at different points in the journey. Staff use a language of recovery rather than goals, and the focus on daily activity and function does not align with client understanding of goals. Process and system barriers were identified.

Discussion: Uncertainty created distress for clients at each time point which manifested in fatigue and non-engagement. Consistent communication is necessary to avoid ambiguity and enhance shared decision making for goals. Broad client goals can be integrated into the service.

Recommendations: This research provides opportunity to improve person centred care for older adults by integrating consistent language and addressing service barriers in clinical practice.

Further research is warranted to investigate goal setting and pursuit for older adults with cognitive or communication deficits and on the psychological and emotional effects of fatigue.